Form Abc-1041 - Microdistillery Monthly Gallonage Tax Return And Sales Report Page 3
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4Kansas Department of Revenue
Alcoholic Beverage Control Division
915 S.W. Harrison Street, Room 214
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 785-296-7185
MICRODISTILLERY MONTHLY GALLONAGE TAX RETURN AND SALES REPORT
MONTH:_______________ YEAR: __________ FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
MICRODISTILLERY NAME:______________________________________________________________________
ADDRESS: ___________________________________________________________________________________
CITY: ________________________________________________________, KS
ZIP CODE: _______________
CONTACT PERSON: ___________________________________________________________________________
EMAIL ADDRESS:_____________________________________________________________________________
No spirits were manufactured this month.
Gallonage tax credit carried forward. Amount: $________________
PRODUCT TYPE:
CODE:
GALLONS
TAX RATE:
TAX AMOUNT:
= $
01
X
$2.50 / Gallon
Spirits
-
$
02
X
$2.50 / Gallon
(GLMD)
-
$
03
X
$2.50 / Gallon
$
Tax Due =
Credit From Previous Report Period -
$
TOTAL TAX DUE =
$
I have paid my gallonage tax using the EFT option.
I declare under penalties of perjury that to the best of my knowledge and belief this is a true, correct and complete return.
SIGNATURE ____________________________________________TITLE ________________________________________________
State if individual owner, member of firm, or title if officer of corporation.
CODES:
01 = Total Gallons of Spirits Manufactured
02 = Sales to Out-of-State Wholesalers
03 = Sales to Non-Beverage Permit Holders
Page 3 of 4
ABC-1041 (Rev. 12.12.12)
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